Transcript Toxic Stress - Academy on Violence and Abuse

Toxic Stress
Robert W. Block, MD, FAAP
AVA Past President and Chair (Until 10 am)
April 19, 2013
My ACE Score of One?
• Loss of a Parent?
• The Story . . . . . . . . . . .
Social Determinants of Health:
Lifetime Consequences of Maltreatment;
Children as the Key to Lifespan Health;
Brain Development Related to Social Determinants.
I have no financial conflicts or disclosures
Allostasis and Allostatic Load
Positive & Tolerable Stress
Toxic Stress
What a Change
“Now, as I said, what a
change! How the
profession throughout the
country is awakening to
the demands of the
times!”
J.P. Crozer Griffith, Section on
Diseases of Children, AMA, 1898
Adversities During Childhood and Toxic
Stress
Pediatrics 2012;129:e224-e231
Pediatrics 2012;129:e232-e246
Epigenetics
Health, Economics, Biology and the Social
Determinants of Well-Being
While not all children are able to
become adults, it
is certainly
true that all adults once
were children.
There is NO Such Thing as Mental
Health!!
• Why the term “Brain Health” might better
represent reality.
The term might facilitate asking and responding to
ACE screening without the STIGMA of “mental
Health.
Just Ask!
Also – Teen Pregnancy Story
Fragile Families
• Most dire straits: without protective family
care.
• Exposed to violence, exploited, abused,
abandoned, severely neglected, homeless, in
institutions, trafficked, gang members,
exploited for labor.
• Poverty plays a role: Disease, health risks,
disabilities, social problems, disasters.
Why is Neglect Important?
• Absence of:
– Sufficient Attention – i.e. “Responsive Care!”
Tennis anyone? Serve and Return.
– Protection.
– All appropriate for the age of the child. Expectations
• Processing information, cognitive, social, and
emotional capacities (competencies) are
distorted.
The Future
• Prevention
• Funding by Merging Science, Medicine, and
Economics
• Will There Be Respect for Childhood?
James J. Heckman
• Nobel Memorial Prize Winner
• Professor of Economics, University
of Chicago
• Equation on Human Capital
Development is a Solution for
Securing America’s Economic Future.
Many major economic and social problems in America — crime,
teenage pregnancy, high school dropout rate, adverse health
conditions — can be traced to low levels of skill and social ability
such as attentiveness, persistence and impulse control.
Professor Heckman found that early nurturing, learning experiences and
physical health from ages zero to five greatly impact success or failure
in society. The most economically efficient time to develop skills and
social abilities is in the very early years when developmental education
is most effective.
Professor Heckman shows that disadvantaged families are least
likely to have the economic and social resources to provide the
early developmental stimulation every child needs as a basic
opportunity for future success in school, college, career and life.
Professor Heckman studied decades worth of data from early
childhood development programs that gave disadvantaged
children and their families developmental support.
The Heckman Equation:
Investing in early childhood
development builds the human
capital we need for economic
success.
Developing a Model of
Human Health and Disease
Biology
Physiologic Adaptations
and Disruptions
Life Course
Science
Through epigenetic mechanisms,
the early childhood ecology becomes
biologically embedded, influencing how the genome is utilized
Social Environment: Example One
• Survey of 67,853 Nurses
– Report childhood physical abuse: 54%
– Report childhood sexual abuse : 34%
• Increased Risk for Adult Type 2 diabetes:
• 26% – 69%, for moderate to
• severe abuse.
• Am J Prev Med, 12/2010
Example Two
• Survey of 68,505 Nurses
• Risk of Uterine Fibroids with increasing
severity of childhood abuse:
• 8% - 36%!
• Also found that an emotionally supportive
relationship during childhood was protective
against this risk.
•
Jarrett RB, Epidemiology, 11/2010
Example Three
• Interpersonal Violence (IPV), and “Housing
Disarray” cause (or, are associated with) an
increase in incidence of childhood asthma.
• Cumulative or Multiple Stressors are most
important.
•
J Epidemiol Community Health, 2010
Example Four
• Among women with chronic pain syndromes,
childhood maltreatment histories were associated
with increased diurnal cortisol levels.
• Abuse can lead to long-term changes in HPA activity.
• Important to evaluate childhood experiences in
fibromyalgia and pain syndrome patients.
Nicolson NA, et al, Psychosomatic Medicine, 2010
Example Five
• Poverty, mediated by chronic stress –
• Associated with decreased working memory in young
adults.
•
•
Evans GW, Schamberg MA, Proceedings
of the National Academy of Science, 2009
Last Example
• Childhood Traumatic Stress –
• Increases the likelihood of hospitalization with
a diagnosed autoimmune disease, “decades
into adulthood.”
•
Dube SR, et al, Psychosomatic Medicine, 2009
PREDISTRIBUTION
• Professor Heckman Returns…….
• Why Not? We would save, literally, hundreds
of billions of dollars!
Thank You for Inviting Me!